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March 2010

Why Work Flow Analysis, Redesign Are Keys to Successful EMR Implementation...and EMR Selection

Work flow analysis and future work flow redesign are often cited as key factors of successful implementations of ambulatory electronic medical records (EMRs) in physician practices.  This is the first in a series of blogs to discuss the value of performing workflow analysis before selecting an ambulatory EMR.

It is unfortunate that work flow analysis, if performed at all, is typically not done until an EMR has been selected and the implementation initiated.  Although physicians intuitively understand the value of good workflows in the office, how workflow analysis helps the physician choose an EMR is not so obvious. 

Workflow analysis can provide the physician practice insights on what to look for in their new EMR product if done early in the selection process.  To get the most out of a work flow analysis it is best to start with a clear purpose in mind.   Some important reasons for initiating work flow analysis before selecting an EMR are to:

  • Identify current office inefficiencies
  • Initiate critical thinking about desired future work flows
  • Develop a prioritized list of desired future workflows (what are the most important ways an EMR is expected to help the practice?)
  • Develop a prioritized list of the most important EMR functionalities that are needed in order to realize these desired future work flows
  • Set realistic expectations on how the EMR is expected to help achieve goals and attain better workflows 

When a work flow analysis is completed the physician practice should expect to see: 

  • Detailed descriptions of current office work flow
  • Detailed work flow maps of key office processes
  • An analysis that identifies current inefficiencies, bottlenecks and opportunities for improvements
  • A high-level outline of desired future workflow redesigns (how the office will work when a EMR is operational)
  • A list of changes that could be made now...even before selecting an EMR

A workflow analysis will initially result in written descriptions of the key processes that the physician practice thrives on each day.  These written descriptions are then synthesized into a workflow map that may look something like this:

Workflow II 

This current workflow map can be used by the practice to design better workflows.  Using the current workflow example from above, the draft development of a future workflow map might initially look something like this:

Workflow III

Developing workflow descriptions and critically thinking about desired future workflows will help identify what an EMR needs to be able to do well for the practice.  Knowing what the EMR needs to do well will help the practice identify and prioritize needed EMR functionalities.  This knowledge will simplify the comparison of EMR products as discussed in the next several blogs.


EMRs create a new medical liability risk-- physician's failure to chase after the non-compliant patient

It is clear that electronic medical records (EMRs) improve patient safety and quality of care in many ways.  It is unclear, however, whether these improvements will result in an overall reduction in medical liability risks and costs.  Consider the following scenarios:

Scenario 1: You are the doctor and you have a 20 year-old female patient, Ann, with insulin-dependent diabetes mellitus who has been an ideal and compliant patient.  When you last saw her 3 months ago you wrote an office note about how her paper log of glucometer readings (that she faithfuly brings in each visit) showed an exellent trend of glucose levels and compliance with her diet and insulin regimen.  A Hgb A1C test was done and the result satisfactory.  Today an emergency room doctor calls you and reports that Ann is comatose with a blood sugar of 650 with other signs of severe ketoacidosis.  You admit her to the intensive care unit where she is treated aggressively but cerebral edema develops resulting in a stroke.  Upon recovery from her metabolic crisis she requires rehabilitation for residual left-sided weakness.  As you piece together her story you discover that since you last saw her she had apparently become acutely depressed after breaking up with her boyfriend.  She now admits to straying from her usual dietary restrictions, failing to take her insulin regularly and not monitoring her blood sugar.  You explain to Ann and her family that her depression obviously led to non-compliance with her diabetes therapy which unfortunately resulted in her poor outcome.

Scenario 2: You are the doctor and you have a 20 year-old female patient, Ann, with insulin-dependent diabetes who has been an ideal and compliant patient.  You last saw her 3 months ago and in your EMR you noted an excellent trend in her daily blood sugar readings that she faithfully sends to your office in real-time (by connecting her home glucometer to the internet through her Xbox).   A Hbg A1C test was done and the result satisfactory.  Today an emergency room doctor calls you and reports that Ann is comatose with a blood sugar of 650 with signs of severe ketoacidosis.  You admit her to the intensive care unit where she is treated aggressively but cerebral edema develops resulting in a stroke.  Upon recovery from her metabolic crisis she requires rehabilitation for residual left-sided weakness.  As you piece together the story you discover that since you last saw her she had apparently become acutely depressed after breaking up with her boyfriend.  She now admits to straying away from her usual dietary restrictions, failing to take her insulin regularly and not monitoring her blood sugar.  When you look in your EMR it is obvious that she stopped sending in her glucose levels 8 days ago.  You were on vacation and the alerts generated by the IT tools were somehow missed by your office personnel.  You explain to Ann and her family that her depression obviously led to non-compliance with her diabetes treatment which led to a severe ketoacidosis complicated by a stroke.  Ann’s parents ask why you would not have checked up on her when she stopped sending in the glucose readings.  They blame you for the poor outcome and file a medical liability suit against you for failing to follow-up on their daughter after your records showed she had become non-compliant. 

The above scenario demonstrates one of several new liability issues raised by the use of electronic health records (EHRs) and other health information technology (IT) tools.  Technology not only changes the way clinicians manage patient care, but also creates new patient care issues to manage.  Other situations prompted by health IT and prone to liability issues include: 

  1. New ways physicians manage population health
  2. Access to previously unavailable patient information through the use of health information exchange (HIE)

EMRs have been shown to improve patient care and patient safety which will hopefully serve as a strong counterbalance to any new liability risks.  However, if medical liability insurance companies discover a need to raise premiums on physicians who adopt health IT tools, then there needs to be open dialogue over who pays for the increase.  Any rise in liability premiums due to health IT adoption needs to be shared by all stakeholders (liability insurance companies, health plans, consumers, employers, hospitals, government, etc...) and not just the doctors.  The rule of thumb for health IT adoption is that, since it is for the public good, all stakeholders get to play and all stakeholders have to pay